Composition for treating joint disease and kit containing same

ABSTRACT

The present invention pertains to a composition for treating joint diseases and a kit including the same, and the purpose of the present invention is to provide a composition for treating joint diseases which can be used in patients with joint diseases, and a kit which includes the same. Specifically provided is a composition for treating joint diseases that obtains higher efficacy than prior preparations by means of a composition for treating joint diseases which includes a modified hyaluronic acid having a group derived from an anti-inflammatory compound or a pharmaceutically acceptable salt of the modified hyaluronic acid, and which is targeted at patients with human joint diseases who have a BMI of 25 kg/m 2  or higher.

TECHNICAL FIELD

The present invention relates to a composition for treating jointdisease, and to a kit containing the composition.

BACKGROUND ART

As society continues to age, osteoarthritis (hereinafter, also referredto as “OA”), a dysfunction due to joint pain and join degeneration,becomes one of the most common joint disease worldwide, and is one ofthe principal causes of physical impairment that interferes with dailyliving in the elderly. Moreover, rheumatoid arthritis (hereinafter, alsoreferred to as “RA”) has been also known as a form of polyarthritisaccompanied by joint swelling and pain. In the case of RA, if thedisease progress over a long period of time, degeneration or deformationof cartilages and bones may also occur as cartilages and bones aredestroyed, restricting the range of joint movement and otherwise causingphysical impairment that interferes with daily living.

At present, preparations using hyaluronic acid and its derivatives areused as drugs for joint disease including osteoarthritis and rheumatoidarthritis. Hyaluronic acid preparations are normally formulated asinjections, and administered directly to the affected joints such asknee and shoulder joints with the aim of suppressing pain and improvingdysfunction due to joint disease through the lubricating action, impactabsorbing action and cartilage metabolism improving action of hyaluronicacid. Commercial hyaluronic acid preparations include those containingpurified sodium hyaluronate as an active ingredient (such as ARTZ® andSUVENYL®. With these preparations, three to five continuousadministrations at a rate of one per week are considered necessary.

Preparations containing crosslinked hyaluronan as an active ingredientinclude those (such as SYNVISC®) requiring three continuousadministrations at a rate of one per week, as well assingle-administration preparations (such as SYNVISC-ONE®, GEL-ONE® andMONOVISC®) with which treatment is completed in a single administration.

Meanwhile, steroids and non-steroidal anti-inflammatory compounds hasbeen known as immediate-acting drugs, and has been also used fortreatment aimed at alleviating joint pain caused by OA and RA and thelike. For example, triamcinolone acetonide is a steroid that is used totreat joint disease including rheumatoid arthritis. Triamcinoloneacetonide is commercially available as a drug for intra-articular cavityinjection, and treatment requires administration every one to two weeks.In the case of non-steroidal anti-inflammatory compounds, ointments andorally administered agents containing diclofenac sodium as an activeingredient has been known for example.

Mixtures or conjugates of hyaluronic acid or its derivatives withsteroids or non-steroidal anti-inflammatory compounds has been alsoknown as active ingredients. For example, a mixture (CINGAL®) ofcrosslinked hyaluronic acid and triamcinolone hexacetonide has beenformulated as a drug for single administration. Some compoundscontaining hyaluronic acid or its derivatives linked to steroids ornon-steroidal anti-inflammatory compounds has been also known. Forexample, Patent Literature 1 and Patent Literature 2 describederivatives containing anti-inflammatory compounds introduced intohyaluronic acid via spacers. These are aimed at achieving both immediatepain relief and long-term pain relief through functional improvement.However, adequate methods for treating OA and PA have not yet beenestablished or provided.

CITATION LIST

[Patent Literature]

Patent Literature 1: WO 2005/066214

Patent Literature 2: Japanese Patent Application Publication No.2016-156029

SUMMARY OF INVENTION

It is an object of the present invention to provide a highly effectivecomposition for treating human joint disease patients.

After exhaustive research into the above problems, the inventors havecompleted the present invention after discovering unexpectedly that acomposition for treating joint disease containing a modified hyaluronicacid or a pharmaceutically acceptable salt thereof having a groupderived from an anti-inflammatory compound has an especially excellentimprovement effect when administered to a particular patient group amongpatients with joint diseases, and that the above problems could besolved with this composition for treating joint disease. Morespecifically, the problems have been solved by using a group of jointdisease patients with a body mass index (hereunder called “EMI” in thisDescription) of at least 25 kg/m² as the target patient group foradministration.

One aspect of the invention relates to a composition for treating jointdisease, containing a modified hyaluronic acid or a pharmaceuticallyacceptable salt thereof having a group derived from an anti-inflammatorycompound, for treating a human joint disease patient with a specifiedBMI. Another aspect of the present invention relates to a method fortreating human joint disease, including a step of administering thiscomposition for treating joint disease into a joint of a patientrequiring it and having a specified BMI. A specified BMI here means aBMI of at least 25 kg/m² for example. Yet another aspect of the present,invention relates to a kit containing the composition for treating jointdisease. This kit includes, for example as one constituent element, asyringe including the composition packed in a syringe barrel.

More particularly, the present invention relates to [1] to [5] below.

[1] A composition for treating joint disease, containing a modifiedhyaluronic acid or a pharmaceutically acceptable salt thereof having agroup derived from a steroidal or non-steroidal anti-inflammatorycompound, for treating a human joint disease patient having a BMI of atleast 25 kg/m².

[2] A kit containing a syringe containing the composition according to[1] above packed in a syringe barrel.

[3] A composition for use in a method for treating joint disease ofhuman joint disease patients, containing a modified hyaluronic acid or apharmaceutically acceptable salt thereof having a group derived from asteroidal or non-steroidal anti-inflammatory compound, wherein themethod is applied to a human joint disease patient having a BMI of atleast 25 kg/m².

[4] The use of a modified hyaluronic acid or a pharmaceuticallyacceptable salt thereof having a group derived from a steroidal ornon-steroidal anti-inflammatory compound in the manufacture of acomposition for treating joint disease, wherein the composition is fortreating joint disease in a human joint disease patient having a BMI ofat least 25 kg/m².

[5] A method for treating human joint disease, including a step ofadministering a composition containing a modified hyaluronic acid or apharmaceutically acceptable salt thereof having a group derived from asteroidal or non-steroidal anti-inflammatory compound to a joint of apatient, wherein the patient is a joint disease patient having a BMI ofat least 25 kg/m².

DESCRIPTION OF EMBODIMENTS

Embodiments of the present invention are explained below with examples.

One aspect of the present invention relates to a composition fortreating joint disease, containing a modified hyaluronic acid or apharmaceutically acceptable salt thereof having a group derived from asteroidal or. non-steroidal anti-inflammatory compound, for treatinghuman joint disease patient with a BMI of at least 25 kg/m².

Another aspect of the present invention relates to a method for treatingjoint disease, including the administration of an effective dose of amodified hyaluronic acid or a pharmaceutically acceptable salt thereofhaving a group derived from a steroidal or non-steroidalanti-inflammatory compound to a human joint disease patient having a BMIof at least 25 kg/m².

Another aspect of the present invention relates to a composition for usein a method for treating a human joint disease patient, wherein thecomposition contains a modified hyaluronic acid or a pharmaceuticallyacceptable salt thereof having a group derived from a steroidal ornon-steroidal anti-inflammatory compound, and the joint disease patienthas a BMI of at least 25 kg/m².

Yet another aspect of the present invention relates to the use of amodified hyaluronic acid or a pharmaceutically acceptable salt thereofhaving a group derived from a steroidal or non-steroidalanti-inflammatory compound in the manufacture of composition fortreating a human joint disease patient, wherein the joint diseasepatient has a BMI of at least 25 kg/m².

With the present invention, particular improvement in medicinal effectscan be achieved in a particular patient group among the human jointdisease patients by using a composition for treating joint diseasecontaining a modified hyaluronic acid or a pharmaceutically acceptablesalt thereof having a group derived from an anti-inflammatory compound.More particularly, excellent improvement effects can be achieved withthe composition for treating joint disease in a group of joint diseasepatients with BMIs of at least 25 kg/m². The present invention providesa method for treating human joint disease patients that is moreeffective than conventional treatment methods, as well as a compositionand kit and the like for use in this treatment method.

As should, be obvious to those skilled in the art, preferred propertiesand features of one aspect of the present invention can be applied toother aspects of the invention.

In this Description, a “hyaluronic acid or a pharmaceutically acceptablesalt thereof” may be called simply a “hyaluronic acid molecule”.Similarly, a “hyaluronic acid or a pharmaceutically acceptable salt,thereof having a group derived from a steroidal or non-steroidalanti-inflammatory compound ” may be called simply a “modified hyaluronicacid molecule”.

In this Description, examples of “pharmaceutically acceptable salts”include, but are not limited to, metal, salts such as sodium, potassium,calcium, magnesium and barium salts; ammonium salts; amine salts such asmethylamine, diethylamine, ethylenediamine, cyclohexylamine andethanolamine salts; inorganic acid salts such as hydrochlorate, sulfate,hydrogen sulfate, nitrate, phosphate, hydrobromide and hydroiodidesalts; and organic acid salts such as acetate, phthalate, fumarate,maleate, oxalate, succinate, methanesulfonate, p-toluenesulfonate,tartrate, bitartrate and malate salts and the like.

In this Description, a “joint disease” is a disease of a joint such as aknee joint, shoulder joint, neck joint, hip joint, spinal joint,temporomandibular joint, finger joint, elbow joint, wrist joint, anklejoint or the like. More specific examples of joint diseases includeosteoarthritis, rheumatoid arthritis, articular cartilage injury,osteonecrosis of the knee, femoral necrosis, shoulder arthritis,bacterial arthritis, viral arthritis, neuropathic joint disease and thelike. The composition for treating joint disease of the invention ispreferably used for osteoarthritis or rheumatoid arthritis, and morepreferably for osteoarthritis. Furthermore the composition for treatingjoint disease of the invention is preferably used to treat joint diseaseof the knee joint. More preferably, the composition for treating jointdisease of the invention is used for osteoarthritis of the knee.

In this Description, “treating” (“treat”, “treatment”) may refer eitherto treatment for the disease itself (for example, treatment to cure orameliorate organic lesions of a disease), or treatment for varioussymptoms (for example, lowered ADL due to joint problems such as pain,stiffness and joint function, which may be evaluated, for example, basedon difficulty in activities of daily living represented by ability toclimb stairs or getting in or out of an automobile). Furthermore,treatment includes not only complete cures, but also improvement in someor all symptoms of the disease, as well as prevention and suppression ofdisease progression (including maintenance and reducing the speed ofdisease progression). Prevention here includes for example preventingthe occurrence of symptoms of joint disease such as joint dysfunction,pain and/or stiffness when such symptoms are not present even thoughorganic lesions are found in the joints. In cases in which no organiclesions are found but symptoms of joint disease such as jointdysfunction, pain and/or stiffness are present, prevention also includespreventing the occurrence of such organic lesions or suppressing thedevelopment of those symptoms that are not yet apparent. The compositionfor treating joint disease of the invention is preferably used toimprove, cure, or suppress the progress of symptoms of joint disease,and more preferably to improve or cure such symptoms. In one embodiment,it can be used favorably to improve, cure or suppress the progress ofjoint pain, or to improve joint function.

In this Description, an “effective dose” means an amount of a componentconsistent with a rational risk/benefit analysis, and sufficient toobtain the desired response without excessive harmful side-effects (suchas toxicity, irritation or allergic response). This “effective dose” mayvary depending on such factors as the symptoms, body type, age, sex andthe like of the patient receiving administration. However, a personskilled in the art does not require individual, testing for eachindividual combination, of these factors, and the effective dose inother cases can be determined based on common technical knowledge andthe results of one or more test examples (for example, the examplesdescribed below).

The hyaluronic acid molecule may be a glycosaminoglycan having a baseskeleton composed of N-acetyl-D-glucosamine (1,3)-β linked toD-glucuronic acid to form disaccharide units (constituent disaccharideunits) that are linked to each other by repeated (1,4)-β bonds, and isnot particularly limited as to structure as long as it is aglycosaminoglycan having such a basic skeleton. Moreover, the hyaluronicacid molecule may be obtained by any method, such as a purified productof animal or microbial origin or a chemically synthesized product or thelike, and one obtained by any of these methods may be used. Thehyaluronic acid molecule in this Description may also have a networkstructure including units of the basic skeleton attached to each othervia crosslinking groups. Examples of hyaluronic acid molecules havingsuch network structures include the compounds described in WO2008-063348 and WO 2011-013902. A person skilled in the art can obtainor prepare these compounds appropriately according to the descriptionsof these publications and technical common knowledge in the field.Moreover, the entire contents of these publications are incorporated byreference in this Description. In one embodiment, the hyaluronic acidmolecule may be one that does not have a network structure introducedbetween units of the basic skeleton by a crosslinking reaction.Moreover, the hyaluronic acid molecule may also be a derivatizedmolecule having a reducing end or one in which some of the hydroxylgroups in the molecule have been acetylated, as long as this does notdetract from, the objects and effects of the present invention.

The weight-average molecular weight of the hyaluronic acid molecule ormodified hyaluronic acid molecule is not particularly limited, but maybe not less than 10,000 and not more than 5,000,000, or preferably notless than 500,000 and not more than 3,000,000, or more preferably notless than 600,000 and not more than 3,000,000, or yet more preferablynot less than 600,000 and not more than 1,200,000. In this Description,the “weight-average molecular weight” is a value measured by theintrinsic viscosity method.

Although the hyaluronic acid molecule and modified hyaluronic acidmolecule used in the invention need not be in the form of salts, theymay be in the form of pharmaceutically acceptable salts. Examples ofpharmaceutically acceptable salts of the hyaluronic acid molecule andmodified hyaluronic acid molecule include metal salts such as sodiumsalts, potassium salts, magnesium salts and calcium salts, and ammoniumsalts and the like. From the standpoint of greater affinity with livingorganisms, the hyaluronic acid salt and modified hyaluronic acid saltused are preferably pharmaceutically acceptable alkali metal salts (suchas sodium or potassium salts), and sodium salts are especiallydesirable.

The modified hyaluronic acid molecule can be obtained by bonding ananti-inflammatory compound to a hyaluronic acid molecule with or withoutan intervening spacer. The modified hyaluronic acid molecule may haveone kind of anti-inflammatory compound or two or more anti-inflammatorycompounds bonded thereto.

The mode of bonding between the hyaluronic acid molecule and theanti-inflammatory compound is not particularly limited as long as itdoes not detract from the desired treatment effects for joint disease inthis case, and may be covalent bonding for example. For example, thehyaluronic acid molecule and anti-inflammatory compound may be bondeddirectly by a bonding mode involving amide bond, ether bonds or thelike. When the hyaluronic acid molecule and anti-inflammatory compoundare bonded via an intervening spacer, the mode of bonding between thehyaluronic molecule and the spacer may be by amide bond, ether bond,ester bond, thioester bond or sulfide bond for example, while the modeof bonding between the spacer and the anti-inflammatory compound may beby amide bond, ether bond, ester bond, thioester bond or sulfide bondfor example.

In a preferred embodiment, the anti-inflammatory compound is bonded tothe hyaluronic acid molecule via a spacer in the modified hyaluronicacid molecule. By selecting a functional group for the spacer thatmatches a functional group of the anti-inflammatory compound, it ispossible to introduce the anti-inflammatory compound into the hyaluronicacid molecule by the desired bonding mode.

From the standpoint of biodegradability, a preferred embodiment providesa modified hyaluronic acid molecule in which a group derived from theanti-inflammatory compound is covalently bonded to a hyaluronic acidskeleton via a spacer represented by Formula (1) below. In thisDescription, a “hyaluronic acid skeleton” is the structural part of themodified hyaluronic acid molecule that derives from a hyaluronic acidmolecule.

[C1]—NR¹—R²—O-   (1)

In Formula (1), R¹ is a hydrogen atom or alkyl group having carbonnumber of not less than 1 and not more than 3; and R² is an optionallysubstituted linear alkylene group having carbon number of not less than1 and not more than 12. R¹ is preferably a hydrogen atom. R² ispreferably an optionally substituted linear alkylene group having carbonnumber of not less than 1 and not more than 4, and more preferably anunsubstituted linear alkylene group having carbon number of not lessthan 1 and not more than 2. For purposes of sustaining the medicinaleffects, R² is still more preferably an ethylene group, and it isespecially desirable for R¹ to be a hydrogen atom and R² an ethylenegroup.

Examples of substituents of R² include aryl groups having carbon numberof not less than 6 and not more than 20, alkoxy groups having carbonnumber of not less than 1 and not more than 11, acyl groups havingcarbon number of not less than 1 and not more than 11, carboxyl groups,and halogen atoms (such as fluorine, chlorine, bromine and iodine atoms)and the like.

From the standpoint of biodegradability, a more preferred embodimentprovides a modified hyaluronic acid molecule containing a constituentdisaccharide unit represented by Formula (2) below.

R¹ and R² in Formula (2) are defined as in Formula (1), and thedefinitions of Formula (1) may be applied appropriately. In Formula (2),X represents a group derived from an anti-inflammatory compound.

To achieve a balance between the effective concentration of theanti-inflammatory compound and the solubility in an aqueous composition,a preferred embodiment provides a modified hyaluronic acid molecule inwhich the proportion of constituent units represented by Formula (2)(corresponding to the introduction rate described below) as a percentageof the total constituent disaccharide units making up the modifiedhyaluronic acid is not less than 0.1 mol % and not more than 80 mol %.The proportion of constituent units represented by Formula (2) as apercentage to the total constituent disaccharide units constituting themodified hyaluronic acid is more preferably not less than 5 mol % andnot more than 50 mol %, or still more preferably not less than 10 mol %and not more than 30 mol %, or yet more preferably not less than 15 mol% and not more than 30 mol %. The proportion of constituent unitsrepresented by Formula (2) can be adjusted by varying the condensingagent, condensing aid, reaction equivalent of the spacer molecule andreaction equivalent of the anti-inflammatory compound and the like inthe reaction step that introduces the anti-inflammatory compound intothe hyaluronic acid molecule. Of the constituent disaccharide units inthe modified hyaluronic acid molecule, a glucuronic acid derived unit ina constituent disaccharide unit other than the constituent disaccharideunit represented by Formula (2) above may have either a carboxyl groupor a carboxylic acid salt group, but preferably has an alkali metal salt(for example sodium or potassium salt) group.

For the compound used as a spacer (spacer compound), a compound havingat least one functional group that binds to the hyaluronic acid moleculeand at least one functional group that, binds to the anti-inflammatorycompound may be selected appropriately according to the mode of bondingbetween the hyaluronic acid molecule and the anti-inflammatory compound.

For example, when introducing a spacer by forming an amide bond with acarboxyl group of the hyaluronic acid molecule, a spacer compound havingan amino group may be selected. When introducing a spacer by forming anester bond with a carboxyl group of the hyaluronic molecule, a spacercompound having a hydroxyl group may be selected. When introducing aspacer by forming an ester bond with a hydroxyl group of the hyaluronicacid molecule, a spacer compound having a carboxyl group may beselected. For the standpoint of ease of introduction into the hyaluronicacid molecule and stability in vivo, a preferred embodiment is a spacercompound having an amino group.

Similarly, when introducing a spacer by forming an ester bond with acarboxyl group of the anti-inflammatory compound, a spacer compoundhaving a hydroxyl group may be selected. When introducing a spacer byforming an amide bond with a carboxyl group of the anti-inflammatorycompound, a spacer compound having an amino group may be selected. Whenintroducing a spacer by forming an ester bond with a hydroxyl group ofthe anti-inflammatory compound, a spacer compound having a carboxylgroup may be selected. When introducing a spacer by forming a thioesterbond with a mercapto group of the anti-inflammatory compound, a spacercompound having a carboxyl group may be selected. From the standpoint ofrelease of the anti-inflammatory compound by biodegradation, the mode ofbonding between the spacer and the anti-inflammatory compound ispreferably ester bonding or thioester bonding, and more preferably esterbonding.

As discussed above, the spacer compound may be selected appropriatelyaccording to the functional groups of the hyaluronic acid molecule andanti-inflammatory compound, and examples include diaminoalkanes havingcarbon number of not less than 2 and not more than 18, optionallysubstituted aminoalkyl alcohols having carbon number of not less than 2and not more than 12, and amino acids and the like. An amino acid may bea natural or non-natural amino acid, without any particular limitations,and examples include glycine, β-alanine and γ-aminobutyric acid.

Using a spacer compound (polyvalent spacer compound) having multiplefunctional groups capable of forming bonds with anti-inflammatorycompounds, it is possible to bond multiple anti-inflammatory compoundsto a single spacer. It is thus possible to introduce multipleanti-inflammatory compounds into a single functional group (such as asingle carboxyl group) of a hyaluronic acid molecule. When using apolyvalent spacer compound, it is also possible to introduce moreanti-inflammatory compounds by reacting only some of the hydrophilicgroups such as carboxyl groups and hydroxyl groups of the hyaluronicacid molecule with the polyvalent spacer compound. This means that apolyvalent spacer compound is advantageous from the standpoint of watersolubility when the composition for treating joint disease is made intoan aqueous composition. Examples of such polyvalent spacer compoundsinclude 2-aminopropane-1,3-diol, serine, threonine,2-amino-1,5-pentanediol, 3-amino-1,2-propanediol,tris(hydroxymethyl)aminomethane, and derivatives of these and the like.

As the method for introducing the spacer and anti-inflammatory compoundinto the hyaluronic acid molecule, the anti-inflammatory compound may beintroduced into a hyaluronic acid molecule having an introduced spacer,or the hyaluronic acid molecule may be reacted with an anti-inflammatorycompound having an introduced spacer.

The methods of bonding the anti-inflammatory compound, hyaluronic acidmolecule and spacer compound are not particularly limited. For example,any method commonly used in such bonding reactions may be used as longas it is a method capable of forming ester bond, amide bond andthioester bond and the like, and the reaction conditions can bedetermined and selected appropriately by a person skilled in the art.

The bonding reaction between the hyaluronic acid molecule and the spacercompound or spacer-bonded anti-inflammatory compound can be achievedusing either a carboxyl group or a hydroxyl group of the hyaluronic acidmolecule, but can be more easily achieved using the carboxyl group dueto the greater reactivity of the functional group. Methods for achievingsuch bonding include for example methods using water-soluble condensingagents such as water-soluble carbodiimides (for example,1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide hydrochloride (EDCI·HCl)or 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide methionodide), methodsusing these condensing agents together with condensing aids such asN-hydroxysuccinimide (HOSu) and N-hydrozybenzotriazole (HOBt), andactive ester methods, acid anhydride methods and the like. Bondingbetween the hyaluronic acid molecule and the spacer compound orspacer-bound anti-inflammatory compound is preferably ester bond oramide bond, and more preferably amide bond.

The introduction rate of the anti-inflammatory compound in the modifiedhyaluronic acid molecule (in this Description, the “introduction rate ofthe anti-inflammatory compound in the modified hyaluronic acid molecule”is sometimes called simply the “introduction rate”) is preferably notless than 0.1 mol % and not more than 80 mol %, or more preferably notless than 5 mol % and not more than 50 mol %, or still more preferablynot less than 10 mol % and not more than 30 mol %, or especially notless than 15 mol % and not more than 30 mol % in order to achieve abalance between the effective concentration of the anti-inflammatorycompound and the solubility in an aqueous composition.

The “introduction rate” in this Description is a value calculated byCalculation Formula 1 below, and can be determined by absorbancemeasurement for example. More specifically, it can be obtained byentering the number of moles of constituent disaccharide units of themodified hyaluronic acid molecule as calculated by the carbazoleabsorbance method and the number of moles of the anti-inflammatorycompound as calculated from a calibration curve prepared in advancebased on the characteristic absorbance values of each anti-inflammatorycompound into the following Calculation Formula 1. The introduction ratecan be adjusted by varying the condensing agent, condensing aid,reaction equivalent of the spacer molecule and reaction equivalent ofthe anti-inflammatory compound and the like in the reaction step ofintroducing the anti-inflammatory compound into the hyaluronic acidmolecule.

[Math. 1]

Calculation Formula 1;Introduction rate (mol %)=(Number of groups derived fromanti-inflammatory compound/number of constituent disaccharide units)×100

In one embodiment, alkali treatment is performed after the reaction thatintroduces the anti-inflammatory compound into the hyaluronic acidmolecule via the spacer. The fluidity of a composition containing themodified hyaluronic acid molecule and the solubility of the modifiedhyaluronic acid molecule in an aqueous solvent can sometimes be improvedin this way. This alkali treatment is not particularly limited as longas it is treatment to make the reaction solution more alkaline after theintroduction reaction. A specific example is a method of adding eitheran organic base or an inorganic base to the solution, and consideringsubsequent treatment and the like it is preferably to add an inorganicbase. In particular, a weak base such as sodium hydrogen carbonate orsodium carbonate is desirable because it is less likely to affect thehyaluronic acid molecule and anti-inflammatory compound. The pHconditions of this alkali treatment may be not less than 7.2 and notmore than 11, or preferably not less than 7.5 and not more than 10 forexample. The treatment time for alkali treatment is also notparticularly limited, but may be not less than 2 hours and not more than12 hours for example, or preferably not less than 2 and not more than 6hours. As a specific example, an anti-inflammatory compound derivativewith an introduced spacer can be first reacted with a hyaluronic acidmolecule, after which a weak alkali such as sodium hydrogen carbonate isadded to the reaction solution and stirred for several hours to treatthe solution, which is then neutralized and post-treated by ethanolsedimentation, drying and the like to obtain the target modifiedhyaluronic acid molecule.

A conventional known steroidal compound or non-steroidal compound havinganti-inflammatory action may be used as the “anti-inflammatory compound”in the present Description,

Specific examples of steroidal anti-inflammatory compounds includehydrocortisone, cortisone acetate ester, dexamethasone, dexamethasonepal/nitate ester, betamethasone, triamcinolone, triamcinolone acetonide,prednisolone, methyl prednisolone, paramethasone acetate ester,halopredone acetate, prednisolone farnesylate, tetracosactide acetateand the like.

In this Description, examples of non-steroidal anti-inflammatorycompounds (hereunder also called “NSAIDs” in the Description) includearylacetic acid compounds (such as indomethacin, sulindac, tolmetin,diclofenac, etodoiac, acemetacin, proglumetacin, amfenac, felbinac,nabumetone, rnofezolac, alclofenac and pharmaceutically acceptable saltsof these compounds and the like), oxicam compounds (such as piroxicam,lornoxicam, raeloxicam, ampiroxicam, tenoxicam and pharmaceuticallyacceptable salts of these compounds and the like), propionic acidcompounds (such as ibuprofen, naproxen, ketoprofen, fenoprofen,flurbiprofen, tiaprofenic acid, oxaprozin, zaltoprofen, loxoprofen,fenbufen, aluminoprofen, pranoprofen, and pharmaceutically acceptablesalts of these compounds and the like), fenamic acid compounds (such asmefenamic acid, flufenamic acid, meclofenamic acid, tolfenamic acid,floctafenine, and pharmaceutically acceptable salts of these compoundsand the like), coxib compounds (such as celecoxib and the like),salicylic acid compounds (such as aspirin, salicylic acid, salsaiate,diflunisal, and pharmaceutically acceptable salts of these compounds andthe like), acetaminophen, tiaramide, epirizole, emorfazone, tinoridine,tolmetin, diflunisal floctafenine, disease-modifying anti-rheumaticdrugs (DMARDs) (such as actarit, salazosulfapyridine, bucillamine,lefiunomide, penicillamine, auranofin, mizoribine, lobenzarit,tacrolimus, methotrexate, infliximab, etanercept, adalimumab, golimumab,certolizumab and tocilizurnab) and the like.

To facilitate introduction of the anti-inflammatory compound into thehyaluronic acid molecule, a compound having a carboxyl group orcarboxylic acid salt group in the side chain, such as indomethacin,sulindac, tolmetin, diclofenac, etodolac, acematacin, amfenac, felbinac,mofezolac, alclofenac, ibuprofen, naproxen, ketoprofen, fenoprofen,flurbiprofen, tiaprofenic acid, oxaprozin, zaltoprofen, loxoprofen,fenbufen, aluminoprofen, pranoprofen, mefenamic acid, flufenamic acid,meclofenamic acid, tolfenamic acid, aspirin, salicylic acid, salsaiate,diflunisal, actarit, salazosulfapyridine, bucillamine or apharmaceutically acceptable salt of these compounds, is preferred out ofthe anti-inflammatory compounds given as examples above.

From the standpoint of its pharmacological effects, theanti-inflammatory compound is preferably an arylacetic acid compoundsuch as those given as examples above, and diclofenac or itspharmaceutically acceptable salt is more preferred.

In a preferred embodiment, a compound having the molecular skeletonrepresented by Formula (3) below is used as the anti-inflammatorycompound.

In Formula (3), Y is a hydrogen atom, sodium atom or potassium atom.

In a more preferred embodiment, a compound represented by Formula (3′)below is used as the anti-inflammatory compound.

In Formula (3′), R³ is selected from a group consisting of the straightor branched chain alkyl groups having carbon number of not less than 1and not more than 6, straight or branched chain alkoxy groups havingcarbon number of not less than 1 and not more than 6 and a hydrogenatom. In one embodiment, R³ is attached at the 5-position when acarboxymethyl group is at position 1 and —NH- is at position 2 on thebenzene ring to which R³ is attached. R⁴, R⁵ and R⁶ are eachindependently selected from a group consisting of the straight orbranched chain alkyl groups having carbon number of not less than 1 andnot more than 6, straight or branched chain alkoxy groups having carbonnumber of not less than 1 and not more than 6, a hydroxyl group, thehalogen atoms (for example, fluorine, chlorine, bromine and iodineatoms) and a hydrogen atom. R⁷ and R⁸ are each independently selectedfrom a group consisting of the straight or branched chain alkyl groupshaving carbon number of not less than 1 and not more than 6, straight orbranched chain alkoxy groups having carbon number of not less than 1 andnot more than 6, a trifluoromethyl group, and the halogen atoms.However, at least, one of R⁷ and R⁸ is a halogen atom. In Formula (3′),Y is defined as in Formula (3). A more preferred example of theanti-inflammatory compound above is diclofenac, in which R³, R⁴, R⁵ andR⁶ are hydrogen atoms, R⁷ and R⁸ are chlorine atoms, and Y is a hydrogenatom.

An example of the compound represented by Formula (3′) above is acompound described in WO 99/11605. The content described in thispublication is incorporated by reference in this Description.

In one embodiment, the composition for treating joint disease of thepresent invention contains the modified hyaluronic acid molecule in theamount of not less than 0.01 wt % and not more than 80 wt % of thecomposition. In another embodiment, the composition for treating jointdisease of the present invention contains the modified hyaluronic acidmolecule in the amount of not less than 0.1 wt % and not more than 10 wt%.

The composition for treating joint disease of the invention may containa pharmaceutically acceptable carrier in addition to the modifiedhyaluronic acid mentioned above. Preferred examples of thispharmaceutically acceptable carrier include aqueous solvents such aswater for injection, phosphate-buffered saltine (PBS), physiologicalsaline and Ringer's solution. In one embodiment, the composition fortreating joint disease is prepared by mixing this physiologicallyacceptable carrier with the modified hyaluronic acid molecule. Additivessuch as buffers may also be added to the composition as necessary.Moreover, the composition for treating joint disease may also be treatedby dust removal, disinfection, sterilization or the like with a filteror the like after the components are mixed.

In one embodiment, the composition for treating joint disease of theinvention is used by administration into a joint at a frequency of onceper period of 4 weeks or more. From the standpoint of the medicinaleffects, the composition for treating joint disease of the invention ispreferably administered once per period of not less than 4 weeks and notmore than 52 weeks, or more preferably once per period of not less than4 weeks and not more than 12 weeks, or still more preferably once perperiod of not less than 4 weeks and not more than 3 weeks, or mostpreferably once in a period of four weeks to less than eight weeks.

In one embodiment, the composition for treating joint disease of theinvention is administered to a joint at a frequency of once about everyfour weeks.

The number of administrations of the composition for treating jointdisease of the invention is determined appropriately according to thecondition of the patient's joint disease, but may be at least one, orpreferably at least two, or more preferably at least threeadministrations.

In a preferred embodiment, the treatment period with the composition fortreating joint disease of the invention extends from the start ofadministration until the patient no longer has subjective symptoms, andthe number of administrations during this treatment period is at leastone. In a more preferred embodiment, the number of administrations ofthe composition for treating joint disease is not less than 2 and notmore than 13, or more preferably not less than 3 and not more than 10.“Subjective symptoms” here mean for example subjective symptomsassociated with pain or physical function (joint function). Subjectivesymptoms can be evaluated for example using the WOMAC® A and C describedin the examples.

In a case of multiple dose administration, individual dosing interval ofthe composition for treating joint disease of the present invention maybe the same or different. However, the joint disease treatment processmay include a dosing interval of less than four weeks. Preferably, eachdosing interval is four weeks or more. In a preferred embodiment, thecomposition for treating joint disease of the present invention isadministered at predetermined intervals of four weeks or more.

In one embodiment, from the perspective of medicinal effect, preferablynot less than 5 mg and not more than 100 mg, or more preferably not lessthan 10 mg and not more than 50 mg, or still more preferably not lessthan 20 mg and not more than 40 mg, or most preferably about 30 mg ofthe modified hyaluronic acid molecule is administered in oneadministration. One aspect of the invention provides a composition fortreating joint disease that is used for such administration.

In one embodiment, from the perspective of medicinal effect, acomposition for treating joint disease containing the anti-inflammatorycompound in the amount of preferably not less than 0.1 mg and not morethan 20 mg, or more preferably not less than 0.5 mg and not more than 10mg, or still more preferably more than not less than 1 mg and not morethan 5 mg is administered per administration. One aspect of the presentinvention provides a composition for treating joint disease that is usedfor such administration.

When the composition for treating joint disease of the present inventionis an aqueous composition containing an aqueous solvent such as thosegiven as examples above, preferably not less than 0.5 ml and not morethan 10 ml, or more preferably not less than 2 mL and not more than 4 mLof the aqueous composition is administered per administration from thestandpoint of convenience of treatment.

In a preferred embodiment, not less than 10 mg and not more than 50 mgof the modified hyaluronic acid molecule per administration isadministered at least twice at a frequency of once every four weeks toless than eight weeks. One aspect of the invention provides acomposition for treating joint disease that is used for suchadministration.

In another preferred embodiment, not less than 20 mg and not more than40 mg of the modified hyaluronic acid molecule per administration isadministered at least three times at a frequency of once every fourweeks to less than eight weeks. One aspect of the invention provides acomposition for treating joint disease that is used for suchadministration.

The mode of administration of the composition for treating joint diseaseof the invention is not particularly limited, and examples includeintraarticular injection, intravenous injection, intramuscularinjection, subcutaneous injection, transdermal injection and the like.The composition for treating joint disease of the invention may beadministered by any oral or non-oral administration route, but ispreferably administered by intraarticular injection.

The dosage form of the composition for treating joint disease of theinvention is not particularly limited, and it may be formulated as aninjection, cream, ointment, solid preparation for external use, lotion,spray, gel, patch or any other dosage form according to theadministration route. Of these, the dosage form of the composition fortreating joint disease of the invention is preferably an injection. Inone embodiment, the composition for treating joint disease of theinvention is administered into a joint as an injection. Theseformulations can be manufactured by ordinary methods.

The composition for treating joint disease of the invention is intendedfor humans (human patients). From the perspective of the medicinaleffects, the composition for treating joint disease of the invention ispreferably administered to a joint disease patient having pain for atleast 12 weeks (that is, the pain duration period is at least 12 weeks).In other words, in one embodiment of the invention the target is a jointdisease patient having pain continuously for at least 12 weeks. “A jointdisease patient having pain for at least 12 weeks” here means a patientwho has had subjective symptoms of pain in the part affected by thejoint disease to be treated continuously for 12 weeks or more before thestart of administration of the composition for treating joint disease ofthe invention.

From a similar perspective, the composition for treating joint diseaseof the invention is more preferably administered to a joint diseasepatient; having pain for at least 26 weeks (about half a year). That is,one embodiment of the invention is targeted at a joint, disease patienthaving pain that has persisted for 26 weeks or more. “A joint diseasepatient having pain for at least 26 weeks” here means a patient who hashad subjective symptoms of pain continuously for 26 weeks or more in thepart affected by the joint disease to be treated before the start ofadministration of the composition for treating joint disease of theinvention.

Although the joint disease treatment of the invention is not restrictedin terms of mechanism, the composition is expected to be especiallyeffective in patients with long pain duration periods due to thesynergistic effect of the anti-inflammatory compound and the hyaluronicacid molecule.

The composition for treating joint disease of the invention isadministered to a joint disease patient having a BMI (patient weight(kg)/(patient height (m))²) of at least 25 kg/m². A BMI of at least 25kg/m² is a benchmark for obesity according to the 2011 obesity criteriaof the Japan Society for the Study of Obesity, and an association withincreased occurrence of complications (such as glucose intolerance,lipid abnormalities, high blood pressure, etc.) has been indicated.

As shown in detail in the examples below, dramatic improvement effectsfrom the composition for treating joint disease of the invention havebeen confirmed in a group of patients with BMIs of at least 25 kg/m² outof the joint disease patients. Even assuming that the burden on thejoints increases (joint disease becomes more likely) as the BMIincreases or in other words as obesity progresses, this dramaticimprovement effect is unexpected considering that a good response fromtreatment was obtained with the composition for treating joint diseasein a group of patients with BMIs within the specified range. Themechanism for this dramatic improvement is unknown, but it is speculatedthat the synergistic effect of the anti-inflammatory compound andhyaluronic acid may be particularly effective in joint disease patientsin whom the burden on the joints is severe due to obesity. Thismechanism is only a speculation, and the joint disease treatment of theinvention is not restricted as to the mechanism of action.

More preferably, the composition for treating joint disease of theinvention is administered to a joint disease patient having a BMI ofless than 35 kg/m². That is, one embodiment of the invention is targetedat joint disease patients with BMIs of not less than 25 kg/m² to lessthan 35 kg/m². This BMI is a value measured within four weeks of thestart of administration of the composition for treating joint disease ofthe invention, and preferably a value measured within two weeks of thestart of administration of the composition for treating joint disease ofthe invention.

One embodiment provides a syringe containing the composition fortreating joint disease of the invention packed in a syringe barrel. Oneembodiment can also provide a kit containing a syringe containing thecomposition for treating joint disease of the invention packed in asyringe barrel. This syringe is equipped with a plunger or the like forejecting the drug, so that the composition for treating joint disease ofthe invention can be ejected. In one embodiment, the composition fortreating joint disease packed in the syringe can be provided in asterile state. In one embodiment, the syringe barrel is filled inadvance with a single dose of the composition for treating jointdisease. The kit may also be a kit containing a solution of the modifiedhyaluronic acid molecule dissolved in phosphate-buffered saline,physiological saline or water for injection and packed in a syringebarrel, together with a medical syringe sealed with a slidable drugejection plunger. A commonly used plunger may be used as the plunger fordrug injection, which is formed from an elastic material such as rubberor synthetic rubber and inserted slidably in tight contact with thesyringe. The kit may also contain a plunger rod for pushing down on theplunger to eject the drug, as well, as an instruction manual, packageinsert or the like.

EMBODIMENTS

Examples of preferred embodiments of the invention are given below.

[1] A composition for treating a human joint disease, wherein thecomposition comprising a modified hyaluronic acid or a pharmaceuticallyacceptable salt thereof having a group derived from a steroidal ornon-steroidal anti-inflammatory compound, which is administered for thejoint disease patient having a BMI of at least 25 kg/m².

[2] The composition according to [1] above, wherein the joint diseasepatient having a BMI of less than 35 kg/m2.

[3] The composition according to [1] or [2] above, which is administeredfor the joint disease patient having duration of pain for 26 weeks ormore.

[4] The composition according to any one of [1] to [3] above, which isan injection.

[5] The composition according to any one of [1] to [4] above, whereinthe group derived from an anti-inflammatory compound is bonded to ahyaluronic acid or a pharmaceutically acceptable salt thereof via aspacer in the modified hyaluronic acid or a pharmaceutically acceptablesalt thereof.

[6] The composition according to [3] above, wherein the mode of bondingbetween the hyaluronic acid or a pharmaceutically acceptable saltthereof and the spacer is selected from the group consisting of amidebond, ether bond, ester bond, thioester bond and sulfide bond. [7] Thecomposition according to [5] or [6] above, herein the mode of bondingbetween the spacer and the group derived from an anti-inflammatorycompound is selected from the group consisting of amide bond, etherbond, ester bond, thioester bond and sulfide bond. [8] The compositionaccording to any one of [1] to [7] above, wherein the group derived froman anti-inflammatory compound is covalently bonded to a hyaluronic acidskeleton via a spacer having a structure of the following Formula (1):—NR¹—R²—O-   (1)

In Formula (1), R¹ is a hydrogen atom or an alkyl group having carbonnumber of 1 to 3; and R² is an optionally substituted linear alkylenegroup having carbon number of 1 to 12.

[9] The composition according to [8] above, wherein R¹ is a hydrogenatom and R² is an ethylene group.

[10] The composition according to any one of [1] to [8] above, whereinthe modified hyaluronic acid or a pharmaceutically acceptable saltthereof contains a structural unit of the following Formula (2):

in Formula (2), R¹ is a hydrogen atom or a alkyl group having carbonnumber of 1 to 3; R² is an optionally substituted linear alkylene grouphaving carbon number of 1 to 12; and X is the group derived from ananti-inflammatory compound.

[11] The composition according to [10] above, wherein R¹ is a hydrogenatom and R² is an ethylene group.

[12] The composition according to [10] or [11] above, wherein thepercent ratio of the number of structural units of the Formula (2) tothe total number of constituent disaccharide units constituting themodified hyaluronic acid or a pharmaceutically acceptable salt thereofis not less than 0.1 mol % and not more than 30 mol %.

[13] The composition according to any one of [1] to [12] above, whereina dose of not less than 5 mg and more than 100 mg by weight of themodified hyaluronic acid or a pharmaceutically acceptable salt thereofis used in a single administration.

[14] The composition according to any one of [1] to [13] above, whereina dose of not less than 0.1 mg and not more than 20 mg by weight of theanti-inflammatory compound is administered in a single administration.

[15] The composition according to any one of [1] to [14] above, whereinthe joint disease is osteoarthritis.

[16] The composition according to any one of [1] to [15] above, whereinthe treatment consists in improving, curing or suppressing the progressof symptoms.

[17] The composition according to [16] above, wherein the treatmentconsists in improving, curing or suppressing the progress of joint pain,or Improving joint function.

[18] The composition according to any one of [1] to [17] above, furthercontaining a pharmaceutically acceptable carrier.

[19] The composition according to any one of [1] to [18] above, whereinthe steroidal or non-steroidal anti-inflammatory compound is diclofenacor a pharmaceutically acceptable salt thereof.

[20] The composition according to any one of [1] to [19] above, whereinthe group derived from a steroidal or non-steroidal anti-inflammatorycompound is bonded to hyaluronic acid or a pharmaceutically acceptablesalt thereof having a weight-average molecular weight of not less than10,000 and not more than 5,000,000 in the modified hyaluronic acid or apharmaceutically acceptable salt thereof.

[21] A kit containing a syringe comprising the composition according toany one of [1] to [20] packed in a syringe barrel.

[22] A composition for use in a method for treating joint disease ofhuman joint, disease patients, containing a modified hyaluronic acid ora pharmaceutically acceptable salt thereof having a group derived from asteroidal or non-steroidal anti-inflammatory compound, wherein themethod is applied to a human joint disease patient having a BMI of atleast 25 kg/m².

[23] The composition according to [22] above, wherein the joint diseasepatient to which the method is applied having a BMI of less than 35kg/m².

[24] The composition according to [22] or [23] above, wherein the methodis applied to a human joint disease patient having duration of pain for26 weeks or more.

[25] The composition according to any one of [22] to [24] above, whereinthe method is performed by injection.

[26] The composition according to any one of [22] to [25] above, whereinthe modified hyaluronic acid or a pharmaceutically acceptable saltthereof includes the group derived from an anti-inflammatory compoundbonded to hyaluronic acid or a pharmaceutically acceptable salt thereofvia a spacer.

[27] The composition according to [26] above, wherein the mode ofbonding between the hyaluronic acid or a pharmaceutically acceptablesalt thereof and the spacer is selected from the group consisting ofamide bond, ether bond, ester bond, thioester bond and sulfide bond.

[28] The composition according to [26] or [27] above, wherein the modeof bonding between the spacer and the group derived from ananti-inflammatory compound is selected from the group consisting ofamide bond, ether bond, ester bond, thioester bond and sulfide bond.

[25] The composition according to any one of [22] to [28] above, whereinthe group derived from an anti-inflammatory compound is covalentlybonded to the hyaluronic acid skeleton via a spacer having a structureof the following Formula (1):

[C7]—NR¹—R²—O-   (1)

in Formula (1), R¹ is a hydrogen atom or a alkyl group having carbonnumber of 1 to 3; and R² is an optionally substituted linear alkylenegroup having carbon number of 1 to 12.

[30] The composition according to [29] above, wherein R¹ is a hydrogenatom and R² is an ethylene group.

[31] The composition according to any one of [22] to [29], wherein themodified hyaluronic acid or a pharmaceutically acceptable salt thereofcontains a structural unit of the following Formula (2):

in Formula (2), R¹ is a hydrogen atom or a alkyl group having carbonnumber of 1 to 3; R² is an optionally substituted linear alkylene grouphaving carbon number of 1 to 12; and X is a group derived from ananti-inflammatory compound.

[32] The composition according to [31] above, wherein R¹ is a hydrogenatom and R² is an ethylene group.

[33] The composition according to [31] or [32] above, wherein thepercent ratio of the number of structural units of the Formula (2) tothe total number of constituent disaccharide units constituting themodified hyaluronic acid or a pharmaceutically acceptable salt thereofis not less than 0.1 mol % and not more than 30 mol %.

[34] The composition according to any one of [22] to [33] above, whereinthe method includes administering a dose of not less than 5 mg and notmore than 100 mg by weight of the modified hyaluronic acid or apharmaceutically acceptable salt thereof in a single administration.

[35] The composition according to any one of [22] to [34] above, whereinthe method includes administering a dose of not less than 0.1 mg and notmore than 20 mg by weight of the anti-inflammatory compound in a singleadministration.

[36] The composition according to any one of [22] to [35] above, whereinthe joint disease is osteoarthritis.

[37] The composition according to any one of [22] to [36] above, whereinthe treatment consists in improving, curing or suppressing the progressof symptoms.

[38] The composition according to [37] above, wherein the treatmentconsists in improving, curing or suppressing the progress of joint pain,or improving joint function.

[39] The composition according to any one of [22] to [38] above, furthercontaining a pharmaceutically acceptable carrier.

[40] The composition according to any of [22] to [39] above, wherein thesteroidal or non-steroidal anti-inflammatory compound is diclofenac or apharmaceutically acceptable salt thereof.

[41] The composition according to any one of [22] to [40] above, whereinthe group derived from a steroidal or non-steroidal anti-inflammatorycompound is bonded to hyaluronic acid or a pharmaceutically acceptablesalt thereof having a weight-average molecular weight of 10,000 to5,000,000 in the modified hyaluronic acid or a pharmaceuticallyacceptable salt thereof.

[42] The use of a modified hyaluronic acid or a pharmaceuticallyacceptable salt thereof having a group derived from a steroidal ornon-steroidal anti-inflammatory compound in the manufacture of acomposition for treating joint disease, wherein the composition is fortreating joint disease in a human joint disease patient with a BMI of atleast 25 kg/m².

[43] The use according to [42] above, wherein the composition is fortreating joint disease in a human joint disease patient with a BMI ofless than 35 kg/m².

[4] A method for treating human joint, disease, including a step ofadministering a composition containing a modified hyaluronic acid or apharmaceutically acceptable salt thereof having a group derived from asteroidal or non-steroidal anti-inflammatory compound to a joint of apatient, wherein the patient is a joint disease patient having a BMI ofat least 25 kg/m².

[45] The method according to [44] above, wherein the patient having aBMI of leas than 35 kg/m².

[46] The method according to [44] or [45] above, wherein theadministration is performed by injection.

EXAMPLES

Preferred embodiments of the invention are explained in detail belowwith reference to examples, but the scope of the present invention is inno way limited to these examples.

Unless otherwise specified, operations and measurements of physicalproperties and the like were performed under conditions of roomtemperature (not less than 20° C. and not more than 25° C.), not lessthan 40% and not more than 50% RH.

Synthesis Examples

Sodium hyaluronate with introduced aminoethanol-diclofenac (testsubstance) was synthesized by the methods described in the examples ofWO 2005/066214 (weight average molecular weight of hyaluronic acid:300,000, introduction rate: 18 mol %).

More specifically, this was synthesized by the following procedures.

2.155 g (10.5 mmol) of 2-bromoethylamine hydrobromide was dissolved, in20 mL of dichl or cinethane, 1.463 ml, (10.5 mmol) of triethylamine wasadded under ice cooling, and 5 mL of a dichloromethane solution of 2.299g (10.5 mmol) of di-tert-butyl-dicarbonate (Boc₂O) was further added andstirred in. This was stirred for 90 minutes at room temperature, ethylacetate was added, and the mixture was separately washed successivelywith 5 wt % aqueous citric acid solution, water, and saturated saline.After dehydration with sodium sulfate, the solvent was distilled offunder reduced pressure to obtain Boc-aminoethyl bromide.

5 mL of a dimethylformamide (DMF) solution of 2.237 g (10.2 mmol) of theBoc-aminoethyl bromide obtained above was ice cooled, 6 mL of a DMFsolution of 3.255 g (10.2 mmol) of diclofenac sodium was added, and themixture was stirred overnight at room temperature. This was stirred for11 hours at 60° C., and then stirred overnight at room temperature.Ethyl acetate was added, and the mixture was separately washedsuccessively with 5 wt % sodium hydrogen carbonate aqueous solution,water, and saturated saline. After dehydration with sodium sulfate, theethyl acetate was distilled off under reduced pressure. The residue waspurified by silica gel column chromatography (toluene:ethyl acetate=20:1(v/v), 0.5 vol % triethylamine) to obtain Boc-aminoethanol-diclofenac.

2.108 g (4.80 mmol) of the Boc-aminoethanol-diclofenac obtained abovewas dissolved in 5 mL of dichloromethane, 20 mL of 4 M hydrochloricacid/ethyl acetate was added under ice cooling, and the mixture wasstirred for 2.5 hours. This was precipitated by addition of diethylether and hexane, and the precipitate was vacuum dried.Aminoethanol-diclofenac hydrochloride was obtained in this way, and thestructure was identified by 1H-NMR:

¹H-NMR (500 MHz, CDCl₃) δ (ppm)=3.18 (2H, t, NH₂CH₂CH₂O-), 3.94 (2H, s,Ph—CH₂—CO), 4.37 (2H, t, NH₂CH₂CH₂O-), 6.47-7.31 (8H, m, Aromatic H,NH).

500 mg (1.25 mmol/disaccharide units) of hyaluronic acid with aweight-average molecular weight of 800,000 was dissolved in 56.3 mLwater/56.3 mL dioxane, 0.5 mL of hydroxysuccinimide (1 mmol)/water, 0.5mL of water-soluble carbodiimide hydrochloride (WSCI·HCl) (0.5mmol)/water, and the aminoethanol-diclofenac hydrochloride (0.5mmol)/(water:dioxane=1:1 (v/v), 5 mL) obtained above were added, and themixture was stirred during a whole day and night. 7.5 mL of a 5 wt %sodium hydrogen carbonate solution was added to the reaction solution,which was then stirred for about 4 hours. 215 μL of a 50% (v/v) aqueousacetic acid solution were added to neutralize the reaction solution,after which 2.5 g of sodium chloride was added and stirred in. 400 ml ofethanol was added to precipitate the solution, and the precipitate waswashed twice with an 85% (v/v) aqueous ethanol solution, twice withethanol and twice with diethyl ether, and vacuum dried overnight at roomtemperature to obtain sodium hyaluronate with introducedaminoethanol-diclofenac (test substance). The diclofenac introductionrate as measured with a spectrophotometer was 18 mol %.

<Test Procedures>

The effectiveness of the investigational drug (test drug (compositionfor treating joint disease of invention) or placebo) when administered 3times at four-week intervals in the knee joint cavities of human kneeosteoarthritis patients was investigated by a multi-centercollaborative, randomized, placebo-controlled, double-blind,parallel-group comparison trial. The test drug and placebo were asfollows:

Test drug: 3 mL of aqueous solution for injection containing 30 mg oftest substance (3.6 mg as diclofenac);

Placebo: 3 mL of aqueous solution for injection containing no testsubstance.

The total amount (3 mL) of the test drug or placebo was administered(injected) into the knee joint cavities of the affected knees of thetarget patients on week 0, week 4 and week 8 for a total of threeinjections.

The target patients were determined based on the following inclusioncriteria 1 to 9 and exclusion criteria 1 to 23.

(Inclusion Criteria)

Patients fulfilling all of the inclusion criteria 1 to 9 below weretargeted.

1. Patients diagnosed with knee OA according to the criteria of theAmerican College of Rheumatology on the screening examination date(performed within two weeks before the initial administration date).

2. Patients having pain due to OA in the target knee beginning 12 weeksor more before the consent date.

3. Patients with a Kellgren and Lawrence (KL) grade of 2 or 3 instanding frontal X-ray image findings on the screening examination date.However, if X-ray images taken within 6 months before the beginning ofscreening are available, these images may be used as a substitute forimages taken on the screening examination date.

-   -   KL grade 2: Mild OA. Micro-osteophyte formation, sometimes        accompanied by narrowing of the joint space, bone hardening or        bone cyst formation    -   KL grade 3: Moderate OA. Osteophytes and moderate narrowing of        the joint space.

4. Patients aged not less than 40 and not more than 75 on the consentdate.

5. Patients having an average value of 5 WOMAC® A (pain) scores and a50-foot walk test pain score of not less than 50 mm and not more than 90mm in the target knee on the screening examination date and initialadministration date.

6. Patients having an average value of 5 WOMAC® A (pain) scores and a50-foot walk test pain score of not more than 30 mm in the non-targetknee on the screening examination date and initial administration date.

7. Patients capable of walking without walking implement (cane, etc.) orassistance.

8.Patients able to discontinue the test drug and drug therapy other thanacetaminophen in the target knee between the screening initiation dateand the end of observation (use of acetaminophen is also prohibitedbeginning two days before hospital visit dates including screening)

9. Patients who have given written consent for participation in thetrial based on free will after receiving sufficient explanation inwriting and understanding its content.

(Exclusion Criteria)

Patients meeting any of the exclusion criteria 1 to 23 below wereexcluded from the trial.

1. Patients in whom the target knee clearly has secondary OA due toother conditions such as injury.

2. Patients having pain other than the target disease in the lower bodythat could affect the evaluation, or patients having OA of the lowerbody other than the knee (ankle OA, hip joint OA, etc.) on the screeningexamination date or initial administration date.

3. Patients having inflammatory disease, infection or the like of thetarget knee joint on the screening examination date or initialadministration date, or patients who suffered from such a disease for aperiod falling within 1 year before the consent date.

4. Patients who have a skin disease or infection of the administrationsite on the screening examination date or initial administration date,and who are therefore at risk of infection from the injection.

5. Patients who have undergone surgical treatment or other invasivetreatment (arthroscopy, joint washing, etc.) of the affected knee withinone year before the initial screening date.

6. Patients who have taken the following drugs within seven days beforethe initial screening date. However, except for diclofenac and opioidanalgesics, in the case of external preparations (other thansuppositories) this applies only to those used on the lower limb on thesame side as the target knee.

-   -   NSAIDs (may be used in combination with low-dose aspirin to        prevent thrombosis)    -   Corticosteroid preparations    -   Opioid painkillers    -   Peripheral neuropathic pain remedies    -   Local anesthetic of the target knee    -   Chondroitin sulfate injection    -   Anticonvulsants, antidepressants, anxiety drugs and Oriental        medicines used for purposes of pain relief

7. Patients who have received intraarticular administration ofcrosslinked sodium hyaluronate preparations (such as SYNVISC®) in theaffected knee within six months before the initial screening date, orpatients who have received intraarticular administration of sodiumhyaluronate preparations (such as ARTZ® and SUVENYL®) in the affectedknee within three months before screening.

8. Patients who have taken the following drugs within 28 days before thestart of screening. However, in the case of external preparations (otherthan suppositories) this applies only to those used on the lower limb onthe same side as the target knee.

-   -   Triamcinolone acetonide    -   Methylprednisolone acetic acid ester    -   Oxaprozin    -   Ampiroxicam    -   Piroxicam

9. Patients who have undergone block therapy (neural block, epiduralblock, facet joint block, etc.) within 28 days before the initialscreening date.

10. Patients who have taken chondroitin sulfate (pharmaceutical productsonly) internally for relief of joint pain within 28 days before theinitial screening date (patients who have been using it continuouslysince 29 days or more before the initial screening date may continuetaking it during the trial).

11. Patients who have undergone physical therapy (exercise therapy,physical therapy, orthosis therapy) for treatment of the target knee OAwithin 28 days before the initial screening date (patients who haveundergone such therapy continuously since 29 days or more before theinitial screening date may continue it during the trial)

12. Patients with BMIs of 35.0 kg/m² or more on the screeningexamination date (or a date close to the initial administration date inthe case of multiple measurements)

13. Women who are pregnant or nursing, or who are shown to be possiblypregnant as the result of a pregnancy test fa pregnancy test isperformed on any woman who could be pregnant; testing is not requiredfor any woman who could not be pregnant, such as those who haveundergone a hysterectomy or bilateral tubal ligation or who appear tohave gone through menopause (two months or more since last menstrualperiod).

14. Patients who have not agreed to appropriate birth control betweenthe consent date and the end of observation

15. Patients suffering from or with a history of aspirin asthma (asthmaattacks induced by NSAIDs or the like)

16. Patients having a history of hypersensitivity to sodium hyaluronate,diclofenac sodium or acetaminophen

17. Patients with a history of (within five years of consent date) orcomplications of malignant tumors. However, those who have been judgedto be cured by surgical treatment or local therapy may participate.

18. Patients having any of the following symptoms or conditions whichmay affect the results of the trial:

-   -   Patients having severe heart disease, liver disease, kidney        disease, blood disease or immunodeficiency    -   Patients having systemic joint disease such as rheumatoid        arthritis or gout    -   Patients having systemic chronic pain disorders such as        fibromyalgia    -   Patients having peripheral neuropathy due to diabetes or the        like

19. Patients having a history or complications of drug addict ion oralcoholism

20. Patients who fail into any of the following categories in clinicalexamination on the screening examination date:

-   -   Patients with AST or ALT levels at least 2.5 times the maximum        reference value of the measuring institution    -   Patients with serum creatinine at least 1.5 times the maximum        reference value of the measuring institution    -   Patients who test positive for hepatitis C antibodies or        Hepatitis B surface antigen.

21. Patients who have participated in trials of the test substance inthe past

22. Patients who have participated in trials of other drugs or medicalequipment within 16 weeks before the consent date

23. Other patients whom the investigative physician or clinical trialphysician has judged to be unsuitable for participation in the trial

The target patients for administration were determined based oninclusion criteria 1 to 0 and exclusion criteria 1 to 23 above.

A total of 176 patients who were found to meet the inclusion criteriaand exclusion criteria were separated randomly .into a test drugadministration group (87 subjects) and a placebo administration group(89 subjects).

[Table 1] below shows the results of a breakdown of each patient groupusing a SMI of 25 kg/m² and pain duration periods (DP) of 26 weeks asthreshold values.

The numbers of patients in Table 1 below correspond to patient numbersat the start of testing.

Effectiveness was evaluated by the following evaluation methods at thetime of the initial administration and at evaluation points 1, 2, 4, 6,8, 10 and 12 weeks after the initial administration.

<Evaluation Methods>

Effectiveness was evaluated using the WOMAC® evaluation (The Journal ofRheumatology 1988; 15:12, p. 1833-1840) developed by Dr. NicholasBellamy. The WOMAC(r) evaluation has been established as a method forevaluating osteoarthritis (The Journal of Rheumatology 2000; 27:11, p.2635-2641).

The patient response method used the VAS (Visual Analog Scale). With theVAS, the degree of a patient's own feelings in response to each questionis indicated by the patient on a 100 mm line, and the degree isevaluated according to the position on the line. Position is representedas length from the left end of the scale. For example, a patient isasked the same question about pain in evaluations before and afteradministration, and the patient responds by indicating a position(degree) on the scale. Numerical values for improvement are thenobtained based on the difference between the length indicated by thepatient before administration (baseline) and the length indicated by thepatient during each evaluation after administration.

<Results>

The improvement effects were quantified based on the difference betweenthe length indicated by the patient before administration (baseline) andthe length indicated by the patient at the time of each evaluation afteradministration. The analysis results for questions about pain (WOMAC® A:evaluates intensity of pain during walking, etc.) are shown in Table 1below. In the table, the lower the value of the change difference below0, the greater the improvement effect.

TABLE 1 Placebo group Test Drug Group Test Drug Group vs. Placebo GroupNumber Lower Upper Number Lower Upper Lower Upper of 95% 95% of 95% 95%Change 95% 95% WOMAC-A patients Change CL* CL patients Change CL CLdifference P value CL CL Whole 89 −21.7 −25.9 −17.5 87 −28.7 −32.9 −24.5 −7.0 0.018 −12.7 −1.2 group BMI <25 47 −23.1 −29.0 −17.2 40 −25.2 −31.1−19.3  −2.1 0.602 −10.2   5.9 (kg/m²) 25≤ 42 −19.1 −25.3 −12.9 47 −32.6−38.7 −26.5 −13.4 0.003 −22.0 −4.9 DP BMI <25 55 −24.1 −29.9 −18.3 49−27.2 −32.9 −21.6  −3.2 0.416 −10.8   4.5 (week) x and/or BMI DP < 26 25≤ BMI 34 −17.0 −23.1 −10.8 38 −30.7 −36.6 −24.7 −13.7 0.002 −22.2 −5.2and 26 ≤ DP *CL = Confidence limit Change: Average value of change frombaseline value (measured before start of administration) 12 weeks afterinitial administration. Estimated by mixed model for repeated measure(MMRM) analysis using the test group, evaluation point, interactionbetween test group and evaluation point, baseline value and KL grade asfixed effects (Correlation structure: unstructured; Degree of freedom:Kenward-Roger Method). Change difference: Change value of test druggroup minus change value of placebo group DP: Duration of pain (weeks)

As shown above, it was found that chronic osteoarthritis could beimproved dramatically in comparison with the placebo group byadministering the composition for treating joint disease of theinvention (test drug) (change difference: −7.0).

In the test drug group, a certain degree of improvement inosteoarthritis was seen even in patients with BMIs of less than 25 kg/m²(change difference: −2.1).

However, in patients with BMIs of at least 25 kg/m² in the test druggroup there was an especially dramatic improvement effect inosteoarthritis in comparison with the placebo group (change difference:−13.4). Even compared with the results for the test drug group as awhole, a greater improvement effect was seen in the test drug groupconsisting of patients with BMIs of at least 25 kg/m².

Of the patients with BMIs of at least 25 kg/m², an extremely greatimprovement effect in osteoarthritis in the test group in comparisonwith the placebo group was seen in those with pain duration periods ofat least 26 weeks.

These analysis results were for pain (WOMAC® A), but a similarimprovement tendency was observed in a physical function evaluation(WOMAC® C: evaluated based on difficulty with activities of daily livingsuch as climbing stairs and getting in and out of automobiles).

<Conclusions>

The composition for treating joint disease of the invention exhibited asignificant improvement effect against joint disease of human jointdisease patients. A particularly dramatic improvement effect was foundin human joint disease patients with BMIs of at least 25 kg/m², andparticularly in patients with BMIs of not less than 25 kg/m² and lessthan 35 kg/m². An extremely great improvement effect was seen inpatients with long pain duration periods of at least DP 26 weeks beforethe initial administration and with BMIs of at least 25 kg/m².

The present invention was described in detail using specific examplesand various embodiments, but a person skilled in the art can easilyunderstand that many modifications and applications of the embodimentsdescribed in this Description are possible as long as they do notdeviate from the spirit and scope of the invention.

The priority claim for this application is based on Japanese PatentApplication No. 2017-49204 submitted to the Japanese Patent Office onMar. 14, 2017 and on Japanese Patent Application No. 2017-132510submitted to the Japanese Patent Office on Jul. 6, 2017, and the entirecontents of those applications are incorporated by reference into thisapplication.

INDUSTRIAL APPLICABILITY

The present invention is industrially applicable in the pharmaceuticalindustry and the like because it provides a composition for treatingjoint disease having a significant effect against joint disease in humanjoint disease patients, together with a method for using thiscomposition for treating joint disease to treat human joint disease.

The invention claimed is:
 1. A method for treating a human jointdisease, comprising: administering a composition comprising a modifiedhyaluronic acid or a pharmaceutically acceptable salt thereof having agroup of a steroidal or non-steroidal anti-inflammatory compound, foruse in a joint disease patient having a BMI of at least 25 kg/m² andless than 35 kg/m², wherein the composition is an injection, and whereinthe steroidal or non-steroidal anti-inflammatory compound is diclofenacor a pharmaceutically acceptable salt thereof.
 2. The method accordingto claim 1, wherein the joint disease patient having duration of painfor 26 weeks or more.
 3. The method according claim 1, wherein the groupof an anti-inflammatory compound is bonded to a hyaluronic acid or apharmaceutically acceptable salt thereof via a spacer in the modifiedhyaluronic acid or a pharmaceutically acceptable salt thereof.
 4. Themethod according to claim 3, wherein the mode of bonding between thehyaluronic acid or a pharmaceutically acceptable salt thereof and thespacer is selected from the group consisting of amide bond, ether bond,ester bond, thioester bond and sulfide bond.
 5. The method according toclaim 3, wherein the mode of bonding between the spacer and the group ofan anti-inflammatory compound is selected from the group consisting ofamide bond, ether bond, ester bond, thioester bond and sulfide bond. 6.The method according to claim 1, wherein the group of ananti-inflammatory compound is covalently bonded to a hyaluronic acidskeleton via a spacer having a structure of the following Formula (1):—NR¹—R²—O-   (1) in Formula (1), R¹ is a hydrogen atom or a alkyl grouphaving carbon number of 1 to 3; and R² is an optionally substitutedlinear alkylene group having carbon number of 1 to
 12. 7. The methodaccording to claim 6, wherein R¹is a hydrogen atom and R² is an ethylenegroup.
 8. The method according to claim 1, wherein the modifiedhyaluronic acid or a pharmaceutically acceptable salt thereof contains astructural unit of the following Formula (2):

in Formula (2), R² is a hydrogen atom or a alkyl group having carbonnumber of 1 to 3; R² is an optionally substituted linear alkylene grouphaving carbon number of 1 to 12; and X is the group of ananti-inflammatory compound.
 9. The method according to claim 8, whereinle is a hydrogen atom and R² is an ethylene group.
 10. The methodaccording to claim 8, wherein the percent ratio of the number ofstructural units of the Formula (2) to the total number of constituentdisaccharide units constituting the modified hyaluronic acid or apharmaceutically acceptable salt thereof is not less than 0.1 mol % andnot more than 80 mol %.
 11. The method according to claim 1, wherein adose of not less than 5 mg and not more than 100 mg by weight of themodified hyaluronic acid or a pharmaceutically acceptable salt thereofis administered in a single administration.
 12. The method according toclaim 1, wherein a dose of not less than 0.1 mg and not more than 20 mgby weight of the anti-inflammatory compound is administered in a singleadministration.
 13. The method according to claim 1, wherein the jointdisease is osteoarthritis.
 14. The method according to claim 1, whereinthe treatment consists in at least one selected from the groupconsisting of improving, curing, and suppressing the progress ofsymptoms.
 15. The method according to claim 14, wherein the treatmentconsists in improving, curing or suppressing the progress of joint pain,or improving joint function.
 16. The method according to claim 1,wherein the composition further comprises a pharmaceutically acceptablecarrier.